Clinical UM Guideline
Subject: Anesthesia Services for Interventional Pain Management Procedures
Guideline #: CG-MED-78 Publish Date: 12/29/2021
Status: Reviewed Last Review Date: 08/12/2021
Description

This document addresses the medical necessity of anesthesia services, including monitored anesthesia care (MAC), for interventional pain management procedures. Interventional pain management procedures include, but are not limited to, diagnostic or therapeutic nerve blocks, diagnostic or therapeutic injections, and percutaneous image guided procedures. This document does not address whether or not reimbursement is provided for the anesthesia service and it is not intended to guide the billing and reimbursement of anesthesia services.

Note: This document does not address moderate sedation. For more information on moderate sedation, please see the following:

Clinical Indications

Medically Necessary:

For interventional pain management procedures, including but not limited to nerve blocks, anesthesia services including monitored anesthesia care (MAC) are considered medically necessary when the following criteria have been met:

  1. There is documentation that the individual's condition requires the presence of qualified anesthesia personnel to perform monitored anesthesia in addition to the physician performing the procedure; and
  2. The medical condition or procedure must be significant enough to require the need for anesthesia services, including MAC. Such conditions or procedures may include, but are not limited to the following:
    1. Significant medical conditions (ASA physical status 3 or above) that increase risk for complications including cardiac disease, pulmonary disease, and morbid obesity (body mass index [BMI] greater than or equal to 40 kg/m2); or
    2. Sleep apnea; or
    3. History of complications during sedation; or
    4. Severe anxiety, psychiatric conditions, or cognitive impairments that decrease safety during the procedure; or
    5. Spasticity or neurological conditions that decrease safety during the procedure; or
    6. Procedures requiring individuals to remain motionless for a prolonged period of time; or
    7. Procedures requiring individuals to remain in a painful position; or
    8. Individuals under the age of 18.

Note: Complex procedures and procedures in high-risk individuals may justify the use of an anesthesiologist or anesthetist to provide conscious sedation or deep sedation. See Appendix for physical status classifications. The presence of a stable, treated condition of itself is not necessarily sufficient.

Not Medically Necessary:

Anesthesia services for interventional pain management procedures are considered not medically necessary for all other indications.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:
For the following anesthesia procedures related to pain management services

CPT

 

01937

Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; cervical or thoracic

01938

Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral

01939

Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; cervical or thoracic

01940

Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral

01941

Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; cervical or thoracic

01942

Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; lumbar or sacral

01991

Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position

01992

Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position

 

 

ICD-10 Diagnosis

 

 

All diagnoses

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

Discussion/General Information

Interventional pain management procedures are typically performed to diagnose or treat chronic pain conditions. These procedures are often performed without the use of sedation or with moderate sedation administered or overseen by the practitioner performing the procedure. However, when the procedure is complex or when the individual has significant medical conditions, a second practitioner may be needed to provide MAC. MAC is an anesthetic service for a diagnostic or therapeutic procedure in which a qualified anesthesia practitioner (for example, an anesthesiologist or nurse anesthetist) provides sedation, monitors vital functions, and treats complications.

In the Position on Monitored Anesthesia Care (ASA, 2018), the American Society of Anesthesiologists (ASA) defines MAC as the following:

Monitored anesthesia care is a specific anesthesia service performed by a qualified anesthesia provider, for a diagnostic or therapeutic procedure. Indications for monitored anesthesia care include, but are not limited to, the nature of the procedure, the patient’s clinical condition and/or the need for deeper levels of analgesia and sedation than can be provided by moderate sedation (including potential conversion to a general or regional anesthetic). Unlike monitored anesthesia care, moderate sedation is a proceduralist directed service which does not include a qualified anesthesia provider’s periprocedural assessment and has the inherent limitations that are policy directed for the non-anesthesia qualified provider. Moderate sedation is a proceduralist directed service that may be governed by separate institutional policies.

Monitored anesthesia care includes all aspects of anesthesia care – a preprocedure assessment and optimization, intraprocedure care and postprocedure management that is inherently provided by a qualified anesthesia provider as part of the bundled specific service. During monitored anesthesia care, the anesthesiologist provides or medically directs a number of specific services, including but not limited to:

Monitored anesthesia care may include varying levels of sedation, awareness, analgesia and anxiolysis as necessary. The qualified anesthesiologist provider of monitored anesthesia care must be prepared to convert to general anesthesia and respond to the pathophysiology (airway and hemodynamic changes) of procedure and position in the management in induction of general anesthesia when necessary.

The ASA, in a Statement on Anesthetic Care During Interventional Pain Procedures for Adults (ASA, 2016), states the following:

The use of moderate (conscious) sedation and/or anesthesia during the performance of pain procedures must be balanced with the potential risk of harm from doing pain procedures in sedated patients. The Committee recognizes the provision of sedation or anesthesia as a separate and distinct service from the pain procedure and thus requiring specific training…The Committee also notes that when moderate (conscious) sedation is provided during the performance of a pain procedure, it should allow the patient to be responsive during critical portions of the procedure, e.g., to report any procedure-related change in pain intensity, function and/or paresthesia.

Many patients can undergo interventional pain procedures without the need for supplemental sedation in addition to local anesthesia. For most patients who require supplemental sedation, the physician performing the interventional pain procedure(s) can provide moderate (conscious) sedation as part of the procedure. For a limited number of patients a second provider may be required to manage moderate or deep sedation or, in selected cases other anesthesia services. Examples of procedures that typically do not require sedation include but are not limited to epidural steroid injections, epidural blood patch, trigger point injections, injections into the shoulder, hip, knee, facet, and sacroiliac joints, and occipital nerve blocks.

Significant anxiety may be an indication for moderate (conscious) sedation or anesthesia services. In addition, procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require sedation or anesthesia services. Examples of such procedures include but are not limited to sympathetic blocks (celiac plexus, paravertebral and hypogastric), chemical or radiofrequency ablation, percutaneous discectomy, trial spinal cord stimulator lead placement, permanent spinal cord stimulator generator and lead implantation, and intrathecal pump implantation. Major nerve/plexus blocks are performed less often in the chronic pain clinic, but the Committee believes that these blocks may more commonly require moderate (conscious) sedation or anesthesia services (e.g., brachial plexus block, sciatic nerve block, and continuous catheter techniques).

The Committee recognizes that pediatric patients may require sedation or anesthesia services for pain procedures because of age-related differences in the approach to this patient population.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Society of Anesthesiologists (ASA). Standards and guidelines. 2020. For additional information visit the ASA website: https://www.asahq.org/standards-and-guidelines. Accessed on June 9, 2021.
Websites for Additional Information
  1. American Society of Interventional Pain Physicians. Available at: http://www.asipp.org/. Accessed on June 9, 2021.
  2. National Institute of Health. NIH Pain Consortium. Available at: https://painconsortium.nih.gov/. Accessed on June 9, 2021.
  3. Society for Pain Practice Management. Available at: http://www.sppm.org/. Accessed on June 9, 2021.
Index

Anesthesia Services
Interventional Pain Management
Monitored Anesthesia Care (MAC)

History

Status

Date

Action

  12/29/2021 Updated Coding section with 01/01/2022 CPT changes; added 01937-01942 effective 01/01/2022 replacing 01935, 01936 deleted 12/31/2021.

Reviewed

08/12/2021

Medical Policy & Technology Assessment Committee (MPTAC) review. References, Websites for Additional Information, and Appendix sections updated.

Reviewed

08/13/2020

MPTAC review. References, Websites, and Appendix sections updated. Reformatted Coding section.

Reviewed

08/22/2019

MPTAC review. Discussion/General Information, References and Websites sections updated.

New

11/08/2018

MPTAC review. Initial document development.

Appendix

American Society of Anesthesiology Physical Status Classifications:

ASA I    A normal healthy patient

ASA II   A patient with mild systemic disease

ASA III  A patient with severe systemic disease

ASA IV  A patient with severe systemic disease that is a constant threat to life

ASA V   A moribund patient who is not expected to survive without the operation

ASA VI  A declared brain-dead patient whose organs are being removed for donor purposes

(ASA Physical Status Classification System, 2020)

 

 

 


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